Curriculum to Accompany

Medical Assisting:

Administrative and Clinical Competencies,

6th Edition

Course:

Preparing for Clinical Duties

Curriculum to Accompany Medical Assisting: Administrative and Clinical Competencies, 6th Edition

Course: Beginning the Patient’s Record

Contents

Part A: In-Person Screening

Part B: The Medical Record

Part C: Body Measurements and Vital Signs

Curriculum to Accompany Medical Assisting: Administrative and Clinical Competencies, 6th Edition

Course: Beginning the Patient’s Record

Course Overview

This module addresses the proper methods for performing in person screening to assure that the sickest patients are seen first in addition to the correct way to obtain and record a patient’s medical history. When a patient is registered to see a health care provider, general demographic information is collected on placed in the record; while this information is important, the medical history is the cornerstone for a viable medical chart for diagnostic and treatment purposes. Also essential to providing appropriate patient care is the collection and documentation of the vital signs – blood pressure, pulse, respiration, and temperature. Body measurements including height and weight are monitored for changes relative to disease processes and the aging process. All of these simple and painless measurements are crucial for health care providers to administer proper care.

Resource List

Textbook:Medical Assisting: Administrative and Clinical Competencies, Sixth Edition, by Lucille Keir, Barbara Wise, Connie Krebs, and Cathy Kelley-Arney. © 2007, Delmar Cengage Learning, ISBN 1-4180-6633-8. Chapter 13.

Student CD-ROM: CD-ROM that accompanies Medical Assisting: Administrative and Clinical Competencies, Sixth Edition. This CD-ROM contains StudyWARE, The Critical Thinking Challenge, and an Audio Library.

Workbook: Workbook to accompany Medical Assisting: Administrative and Clinical Competencies, Sixth Edition, by Lucille Keir, Barbara Wise, Connie Krebs, and Cathy Kelley-Arney. © 2007, Delmar Cengage Learning, ISBN 1-4180-3267-0. Chapter 13.

Instructor’s Materials: Instructor’s Resource Manual to accompany Medical Assisting: Administrative and Clinical Competencies, Sixth Edition,by Lucille Keir, Barbara Wise, Connie Krebs, and Cathy Kelley-Arney. © 2007, Delmar Cengage Learning, ISBN 1-4180-3268-9.

Instructor’s CD-ROM: Electronic Classroom Manager to accompany Medical Assisting: Administrative and Clinical Competencies, Sixth Edition, by Lucille Keir, Barbara Wise, Connie Krebs, and Cathy Kelley-Arney. © 2007, Delmar Cengage Learning, ISBN 1-4180-3269-2.

The Internet: It is strongly recommended that faculty and learners alike have a working knowledge of the Internet.

Equipment List

  1. Multimedia projector
  2. Computer with Internet access
  3. Multimedia equipment
  4. AAMA credentialing information
  5. AMT credentialing information
  6. DVD player

CAAHEP content

III.C.1.g(4)Patient care and instruction

ABHES content

VI.B.1.b.9.a.Basic clinical skills

VI.B.1.b.9.b.Basic skills and procedures used in medical emergencies

VI.B.1.b.9.c.1.Patient examination – patient histories

VI.B.1.b.9.c.2Patient examination – patient preparation

CAAHEP competencies

III.C.3.b.(4)(a)Perform telephone and in-person screening

III.C.3.b.(4)(b)Obtain vital signs

III.C.3.b.(4)(c)Obtain and record patient history

III.C.3.b.(4)(d)Prepare and maintain examination and treatment areas

III.C.3.c.(3)(b)Instruct individuals according to their needs

III.C.3.c(3)(c)Provide instruction for health maintenance and disease prevention

III.C.3.c.(4)(b)Perform routine maintenance of (administrative and) clinical equipment

ABHES competencies

VI.B.1.a.4.a.Interview and record patient history

VI.B.1.a.4.b.Prepare patients for procedures

VI.B.1.a.4.d.Take vital signs

VI.B.1.a.4.g.Prepare and maintain examination and treatment area

VI.B.1.a.7.bInstruct patients with special needs

VI.B.1.a.7.cTeach patients methods of health promotion and disease prevention

Learning Activities

(HW)Terminology Notebook. Assign chapter for reading and have students define key terms and retain in a key term notebook for future reference.

(ICA)Role Play Telephone Screening. Provide the students with pre-planned scenarios to role play telephone screening procedures.

(ICA)Prioritizing Activity. Give the students various chief complaints and nonverbal messages on cards; have other students screen them for priority according to complaints and body language.

(ICA)Charting Chief Complaints. Design several patient complaints to allow the students practice in charting chief complaints correctly.

(ICA)Competency evaluation, Procedure 13-1. Evaluate students for competency in performing in-person screening.

(HW)Chapter 13, Unit 1 Workbook Assignment Sheet

(ICA)Genogram Activity. Assign students to map their own genogram

(ICA)Competency evaluation, Procedure 13-2. Pair up the students to obtain and record patient history for evaluation of competency.

(HW)Chapter 13, Unit 2 Workbook Assignment Sheet

(ICA)Maintaining the scale. Gather the class around the scale to demonstrate how to properly balance, read, and maintain the scales. Set the weights at different levels for the students to calculate the correct weights. Demonstrate the proper method for obtaining these two measurements.

(ICA)Partner activity. Assign partners and have the students to weight and measure one another and record their results.

(ICA)Competency evaluations, Procedures 13-3 and 13-4. Evaluate students on measuring height and weight on a balance beam scale.

(ICA)Thermometer identification. Display several types of thermometers in the classroom for students to classify the types set out.

(ICA)Competency evaluations, Procedures 13-5 through 13-10. Provide the opportunity for the students to practice taking temperatures with numerous thermometers and record their results. Evaluate them for competency on the procedures for which you have the type of thermometer listed.

(ICA)Temperature conversions. Give the students five Fahrenheit and five Celsius temperatures to convert to the opposite type without calculators.

(ICA)Palpating the pulse activity. Ask the students to point out the pulse points and palpate them on their bodies.

(ICA)Taking pulses demonstration. Demonstrate the approved methods for obtaining radial and apical pulses.

(ICA)Competency evaluations, Procedures 13-11 and 13-12. Pair the students off to practice pulse measurement followed by evaluation ofcompetency.

(ICA)Respirations pop quiz. Quiz the students on the proper steps for counting respirations.

(ICA)Blood pressure display. Exhibit the equipment needed for obtaining a blood pressure. Demonstrate the method for measuring a blood pressure.

(ICA)Recognizing Korotkoff sounds. Use a teaching stethoscope with each student to assist them in recognition of the Korotkoff sounds.

(ICA)Competency evaluation, Procedure 13-14. Following ample practice time and assistance, evaluate the students on Procedure 13-14 by using the teaching stethoscope to ensure accuracy of the students’ results.

(HW)Chapter 13, Unit 3 Workbook Assignment Sheet

(HW)The Critical Thinking Challenge, page 672.

(HW)The StudyWare Challenge, Chapter 13. Have students take the Quiz in “Quiz Mode” and either email their scores to the instructor, or print the scores to turn in.

(ICA)Following review of the chapter and homework assignments, give a quiz on this chapter that includes the content and competencies listed for CAAHEP and ABHES.

Part A: In-Person Screening

Learning Objectives

Cognitive

  1. Spell and define the Words to Know in this unit.
  2. Explain the origin of triage.
  3. Explain the purpose of screening in today’s medical office.
  4. List the categories for determining the urgency of a patient’s condition.

Psychomotor

  1. Perform in-person screening.

Key Concepts / References & Activities / Slides
Screening / Page 628
(HW) Terminology Notebook / 3-5
Telephone screening / Page 629
(ICA) Role Play Telephone Screening
In-person screening / Page 629-630
(ICA) Prioritizing Activity
(ICA) Charting Chief Complaint / 6
Conducting the in-person screening / Page 631-632
(ICA) Complete Procedure 13-1 / 7-8
(HW) Chapter 13, Unit 1 Workbook Assignment Sheet

(ICA) In-Class Activities

  1. Role Play Telephone Screening. Provide the students with pre-planned scenarios to role play telephone screening procedures.
  2. Prioritizing Activity. Give the students various chief complaints and nonverbal messages on cards; have other students screen them for priority according to complaints and body language.
  3. Charting Chief Complaints. Design several patient complaints to allow the students practice in charting chief complaints correctly.
  4. Competency evaluation, Procedure 13-1. Evaluate students for competency in performing in-person screening.

(ICD) In-Class Discussion

  1. What is the definition of screening?

Screening is the process of obtaining information from patients in order to determine their medical condition.

  1. What patient complaint is always given the highest priority?

Difficulty in breathing takes top priority.

  1. Name some skills required for telephone screening.

Individuals assigned to telephone screening should have: good communication skills; the ability to solve problems; good decision-making skills; compassion; and, self-control.

  1. What is the difference in subjective and objective symptoms?

With subjective symptoms, only the patient can perceive the symptom – symptoms may include pain, dizziness, itching, and/or numbness. Objective symptoms are observable to another and include such signs as bruising and swelling.

  1. True or False: The chief complaint must be recorded in the patient’s own words.

True; the medical assistant should use the patient’s exact words when recording the chief complaint.

(HW) Homework Assignments

  1. Terminology Notebook. Assign the unit for reading and have students define key terms and retain in a key term notebook for future reference.
  2. Chapter 13, Unit 1 Workbook Assignment Sheet.

Presentation Tools

Note to Instructors: If you change Objectives or Assignments, don’t forget to change the slides accordingly.

Chapter 13, Slides 1-2 / Introduce the course and unit.
Slides 3-5 / Screening
Slide 6 / In-person screening
Slides 7-8 / Conducting the in-person screening
Slide 9 / Have students answer the checkpoint questions on the slide to review the content in the unit.

Part B: The Medical Record

Learning Objectives

Cognitive

  1. Spell and define the Words to Know in this unit.
  2. Identify the 10 categories of information requested on the health history form in Figure 13-4.
  3. Explain the purpose of obtaining a health history.
  4. Discuss the genogram and explain why it is useful.

Psychomotor

  1. Obtain and record a patient history.

Key Concepts / References & Activities / Slides
Medical history / Page 633
Figure 13-4
(HW) Terminology Notebook / 11
Family history and genograms / Page 633
Figure 13-5
(ICA) Genogram Activity / 13
Obtaining the medical history / Pages636-637
(ICA) Complete Procedure 13-2 / 12
Patient education / Pages 637-638
(HW) Chapter 13, Unit 2 Workbook Assignment Sheet

(ICA) In-Class Activities

  1. Genogram Activity. Assign students to map their own genogram
  2. Competency evaluation, Procedure 13-2. Pair up the students to obtain and record patient history for evaluation of competency.

(ICD) In-Class Discussion

  1. What do these abbreviations represent: CC, PI/HPI, OTC, ROS, PH/PMH, UCHD, FH, NKDA?

CC=chief complaint; PI/HPI=present illness/history of present illness; OTC=over the counter; ROS=review of systems; PH/PMH= past history/past medical history; UCHD=usual childhood diseases; FH=family history; and NKDA=no known drug allergies

  1. What is the next step after completing the patient history?

Weigh and measure the patient followed by measuring and recording the vital signs.

(HW) Homework Assignments

  1. Terminology Notebook. Assign the unit for reading and have students define key terms and retain in a key term notebook for future reference.
  2. Chapter 13, Unit 2 Workbook Assignment Sheet.

Presentation Tools

Note to Instructors: If you change Objectives or Assignments, don’t forget to change the slides accordingly.

Chapter 13, Slide 10 / Introduce the unit.
Slide 11 / Medical history
Include surgeries and immunizations with the discussion
Slide 12 / Obtaining the medical history
Slide 13 / Family history and genograms
Slide 14 / Have students answer the checkpoint questions on the slide to review the content in the unit.

(ICD)Ask the students to discuss why each of the seven points in patient education is important

Part C: Body Measurements and Vital Signs

Learning Objectives

Cognitive

  1. Spell and define the Words to Know in the unit.
  2. Explain why a patient’s height and weight is measured at the initial and follow-up visits.
  3. Identify the four vital signs and the body functions they measure.
  4. Explain how the body controls temperature.
  5. Explain situations in which oral measurement is contraindicated.
  6. Identify the average normal temperature and relative accuracy for oral, axillary, and rectal measurement.
  7. Describe what causes pulse and why it can be eflt; name and locate the five pulse points.
  8. Identify normal pulse rates and describe five factors that affect the rate.
  9. Name two pulse characteristics besides rate and give descriptive words that define their meanings.
  10. Name at least five indications for apical pulse measurement.
  11. Define pulse deficit, explaining its significance and how it is measured.
  12. List the five circulatory factors reflected by the measurement of blood pressure.
  13. List the five circulatory factors reflected by the measurement
  14. Explain how the body maintains blood pressure.
  15. Identify the phases of blood pressure, comparing them to the action of the heart.
  16. Name six terms used to define types of hypertension.
  17. Explain how pulse pressure is determined.
  18. Explain an ausculatory gap.

Psychomotor

  1. Measure and record height.
  2. Measure and record weights.
  3. Measure and record oral, axiliary, and rectal temperature with an electronic thermometer.
  4. Measure and record oral temperature with a disposable thermometer.
  5. Measure and record core body temperature with an infrared tympanic thermometer.
  6. Measure and record temperature with a temporal artery thermometer.
  7. Measure and record radial and apical pulse rates.
  8. Measure and record respirations.
  9. Measure and record blood pressure.

Initial Questions and Activities

Discuss the causes in variance of the body’s temperature as well as the normal temperatures for the three different routes

Key Concepts / References & Activities / Slides
Body measurements / (HW) Terminology Notebook
Pages 640-644
Figure 13-10
(ICA) Maintaining the scale
(ICA) Partner activity
(ICA) Procedures 13-3 and 13-4 / 16-17
Temperature / Page 645
Table 13-1 / 21-23
Comparison of thermometer types / Page 647
Table 13-3
(ICA) Thermometer identification
Measuring temperature—oral, rectal, axillary, aural, temporal artery / Pages 647-658
(ICA) Procedures 13-5 to 13-10 / 24
Converting temperatures / Page 658
Table 13-4
(ICA) Temperature conversions
Pulse points, rates and characteristics / Page 659-660
Figure 13-20
(ICA) Palpating the pulse activity
(ICA) Taking pulses demonstration / 25-29
Measure the radial pulse and apical pulse / Page 660
Figure 13-11
(ICA) Procedures 13-11 and 13-12 / 30-31
Respiration / Page 662-663 / 32-34
Measure respiration / Page 665
(ICA) Respirations pop quiz
(ICA) Procedure 13-13
Temperature-Pulse-Respiration ratio / Page 664
Table 13-6
Measuring blood pressure / Pages 664-666 / 35-38
Classification and management of blood pressure for adults / Page 667
Table 13-7
Equipment for blood pressure / Pages 667-668
Measuring techniques / Pages 668-672
(ICA) Blood pressure display
(ICA) Recognizing Korotkoff sounds
(ICA) Procedure 13-14
Auscultatory gap / Page 670
(HW) Chapter 13, Unit 3 Workbook Assignment Sheet
(HW) The Critical Thinking Challenge, page 672
(HW) The StudyWare Challenge, Chapter 13
(ICA) Quiz on chapter material

(ICA) In-Class Activities

  1. Maintaining the scale. Gather the class around the scale to demonstrate how to properly balance, read, and maintain the scales. Set the weights at different levels for the students to calculate the correct weights. Demonstrate the proper method for obtaining these two measurements.
  2. Partner activity. Assign partners and have the students to weight and measure one another and record their results.
  3. Competency evaluations, Procedures 13-3 and 13-4. Evaluate students on measuring height and weight on a balance beam scale.
  4. Thermometer identification. Display several types of thermometers in the classroom for students to classify the types set out.
  5. Competency evaluations, Procedures 13-5 through 13-10. Provide the opportunity for the students to practice taking temperatures with numerous thermometers and record their results. Evaluate them for competency on the procedures for which you have the type of thermometer listed.
  6. Temperature conversions. Give the students five Fahrenheit and five Celsius temperatures to convert to the opposite type without calculators.
  7. Palpating the pulse activity. Ask the students to point out the pulse points and palpate them on their bodies.
  8. Taking pulses demonstration. Demonstrate the approved methods for obtaining radial and apical pulses.
  9. Competency evaluations, Procedures 13-11 and 13-12. Pair the students off to practice pulse measurement followed by evaluation ofcompetency.
  10. Respirations pop quiz. Quiz the students on the proper steps for counting respirations.
  11. Blood pressure display. Exhibit the equipment needed for obtaining a blood pressure. Demonstrate the method for measuring a blood pressure.
  12. Recognizing Korotkoff sounds. Use a teaching stethoscope with each student to assist them in recognition of the Korotkoff sounds.
  13. Competency evaluation, Procedure 13-14. Following ample practice time and assistance, evaluate the students on Procedure 13-14 by using the teaching stethoscope to ensure accuracy of the students’ results.
  14. Following review of the chapter and homework assignments, give a quiz on this chapter that includes the content and competencies listed for CAAHEP and ABHES.

(ICD) In-Class Discussion

  1. Name two methods of mensuration.

Height and weight

  1. What are the cardinal (vital) signs?

Temperature, blood pressure, pulse, and respirations

  1. What structure governs the body’s temperature?

The hypothalamus

  1. What is the series of events when the body is too warm?

The brain sends a message to the sweat glands to produce perspiration that evaporates to cool the body. Also, nerve impulses relay messages to the blood vessels to dilate (expand) to allow more heat to escape that in turn helps to cool the body.

  1. When is taking an oral temperature contraindicated?

Infants/children less than six years old; respiratory complications resulting in mouth breathing or the use of nasal oxygen; confused, disoriented or emotionally unstable patients; patients with oral injuries; patients that have had recent oral surgery; patients with facial paralysis; patients with nasal obstruction; unconscious patients